Repeat Hospital Visits Don't Lower Deaths

Some hospitals with high readmission rates say they’re saving lives by bringing patients back at the first hint of trouble. The evidence for this is that a handful of hospitals with high readmission rates also have extremely low death rates among Medicare patients.

But a study published Tuesday finds that there's no major link between hospitals with high readmissions and those with low mortality rates. The findings come as Medicare ramps up financial penalties for hospitals with higher readmission rates in an effort to improve quality and contain costs.

Writing in the Journal of the American Medical Association, researchers found no relationship between readmissions and mortality rates for Medicare patients who had heart attacks or pneumonia between 2005 and 2008. The paper did find a "modest" inverse relationship between readmissions and death rates for heart failure patients, where hospitals with low death rates tended to have somewhat higher readmission rates. But that was only for a small portion of hospitals and not strong even then.

"I feel we've dispelled the notion that your performance in mortality will dictate your performance in readmission," said Dr. Harlan Krumholz of Yale University School of Medicine, the lead author of the study. "This result says they appear to be measuring different things, they're not strongly related to each other and you can clearly do well on both."

Krumholz does work for the Centers for Medicare & Medicaid Services (CMS) in developing and assessing measures of hospital quality, including the ones for readmissions and mortality.

His study has not quelled the debate among researchers, including ones from the Cleveland Clinic, who previously suggested that higher readmission rates might be the consequence of successful care.

Dr. Bruce Lytle, chairman of The Cleveland Clinic's heart and vascular programs, said he considered the Krumholz's finding about heart failure readmissions more significant than Krumholz gave it credit for. "He got very similar results from what we noted," Lytle said. "He tends to feel it's not a big inverse association. But big and small are a matter of interpretation."

Medicare data released last year showed that two hospitals, Beth Israel Deaconess Medical Center in Boston and Olympia Medical Center in Los Angeles, had higher than average readmission rates for all three conditions that Medicare tracks publicly: heart attack, heart failure and pneumonia, but lower rates of mortality within 30 days of discharge for patients with those three conditions. Thirty-one hospitals other than Israel and Olympia had low mortality for heart failure patients even though they had high readmission rates.

Dr. Ashish Jha, a professor at the Harvard School of Public Health who has written skeptically about the readmission measure, said Krumholz’s analysis strengthened his concerns that readmissions are not a trustworthy way to gauge the quality of hospitals.

Jha said that most hospital quality measures tend to move in tandem: for instance a hospital that frequently follows the appropriate methods of care also tends to do well in keeping patients alive. But Jha said Krumholz's study showed there was no connection between hospitals that do well on keeping patients alive and keeping them from returning.

"This paper offers strong evidence that readmissions is not a good measure of the quality of hospital care," Jha said. "It may be a good way to promote greater accountability for what happens to patients after they leave. But, as a measure of hospital quality, not as much."

This year, 2,217 hospitals are getting lower Medicare payments because too many patients were readmitted. Hospitals have been objecting to the readmissions penalties, which under the federal health law will rise incrementally to a maximum of 3 percent of all regular Medicare payments in October 2015.

A widely cited study by researchers at the David Geffen School of Medicine at UCLA in Los Angeles backed the notion that more aggressive care can save lives. The study of heart failure patients at California teaching hospitals found that the hospitals that used more resources during the 180 days after a patient was admitted had lower mortality rates.

Dr. Michael Ong, an author of the UCLA study, called Krumholz’s study "probably the most helpful study to date on this question" because it included more than just heart failure patients. But he said it will still be important to monitor patient health as hospitals take more substantial steps to reduce readmissions now that the penalties have kicked in.

"In the drive to reduce costs, I think it's important for people who are doing evaluations to track both [readmissions and mortality] outcomes to ensure they are not causing harm," Ong said.

The American Hospital Association has strongly criticized the readmissions penalties. An AHA research brief in 2011 said: "[G]rowing evidence reveals that mortality and readmissions may in fact be inversely associated with one another, calling into question the assumption that low readmission rates are always desirable."

In an interview Tuesday, Nancy Foster, an AHA vice president, said the Krumholz paper was a good start at examining the relationship between readmissions and patient outcomes but she wasn't persuaded that there aren’t adverse consequences when hospitals cut readmissions.

The analysis on which Krumholz's paper was based was performed as part of a contract Krumholz and fellow Yale researchers have with CMS. The Yale New Haven Health Services Corporation Center for Outcomes Research and Evaluation produces an annual performance report on readmission and mortality measures for CMS. The most recent report found a wide variation among hospitals not only for readmissions for heart and pneumonia patients but also for complication and readmission rates for those who underwent hip and knee replacements – indicating that some hospitals do a better job than others in making sure patients in elective surgeries heal properly.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente. This article was produced in collaboration with support from The SCAN Foundation.